Non-qualified Assistants Charting?

[Jen 0]

I recently was sent by my corp. to another state to a sister facility to do some mentoring. The AD had her assistants who have not completed their state-approved AD course writing care plans, progress notes, & completing the MDS. There was another AD from a nearby state there who also was having her assistants do the same & they both had been doing this for years with no problems with survey. I've been doing this for a looong time (17 yrs.) & always understood the F tag 249 as you had to be qualified to do the paperwork. Does anyone else been having their unqualified assistants do documentation? Please enlighten me if I'm wrong!

[KateAA 0]

My staff does the assessments, care plans, MDS and progress notes. As all have more than two years experience they are considered qualified Activity Directors under FTag249. However, even my part-time people assist with the paperwork and they have less than 6 month's experience. Here is the information from the Interpretive Guidleines from 2006:

 

"ASSESSMENT

 

The information gathered through the assessment process should be used to develop the activities component of the comprehensive care plan. The ongoing program of activities should match the skills, abilities, needs, and preferences of each resident with the demands of the activity and the characteristics of the physical, social and cultural environments.5

 

In order to develop individualized care planning goals and approaches, the facility should obtain sufficient, detailed information (even if the Activities RAP is not triggered) to determine what activities the resident prefers and what adaptations, if any, are needed.6 The facility may use, but need not duplicate, information from other sources, such as the RAI, including the RAPs, assessments by other disciplines, observation, and resident and family interviews. Other sources of relevant information include the resident’s lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences.7 This assessment should be completed by or under the supervision of a qualified professional (see F249 for definition of qualified professional)."

 

 

And

 

"ACTIVITIES DIRECTOR RESPONSIBILITIES

 

An activity director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment; and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident. "

 

So it's my responsibility to delegate and supervise their paperwork, thus freeing me up to do activities with the residents, which I enjoy doing.

[KateAA 0]

My staff does the assessments, care plans, MDS and progress notes. As all have more than two years experience they are considered qualified Activity Directors under FTag249. However, even my part-time people assist with the paperwork and they have less than 6 month's experience. Here is the information from the Interpretive Guidleines from 2006:

 

"ASSESSMENT

 

The information gathered through the assessment process should be used to develop the activities component of the comprehensive care plan. The ongoing program of activities should match the skills, abilities, needs, and preferences of each resident with the demands of the activity and the characteristics of the physical, social and cultural environments.5

 

In order to develop individualized care planning goals and approaches, the facility should obtain sufficient, detailed information (even if the Activities RAP is not triggered) to determine what activities the resident prefers and what adaptations, if any, are needed.6 The facility may use, but need not duplicate, information from other sources, such as the RAI, including the RAPs, assessments by other disciplines, observation, and resident and family interviews. Other sources of relevant information include the resident’s lifelong interests, spirituality, life roles, goals, strengths, needs and activity pursuit patterns and preferences.7 This assessment should be completed by or under the supervision of a qualified professional (see F249 for definition of qualified professional)."

 

 

And

 

"ACTIVITIES DIRECTOR RESPONSIBILITIES

 

An activity director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion and/or directing/delegating the completion of the activities component of the comprehensive assessment; and contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident. "

 

So it's my responsibility to delegate and supervise their paperwork, thus freeing me up to do activities with the residents, which I enjoy doing.

[Pennie 26]

You should also pay attention to the fact that the charts are medical records and the Person that will take responsibility for errors that may have caused injury or records that may have been erased and edited illegally will be the Activity Director Certified or TR Certified that signs off on each entry.. If your facility accepts Medicaid or Medicare than your charts are federal records and if a problem arises that threatens the corporation, they may hold the Certifier partially responsible.

 

I would make sure if your assistants and staff are help with the documentation, that you have each enter the changes on a in-dept. form which should be examined by the AD /certified , not qualified, but Certified and then entered into the records by the responsible party.

 

You can look thru the regs in the http://www.activitydirector.net Downloads Area and also search the State Government Site and CMS (Centers for Medicare/Medicaid Services) websites for any further clarification..

 

hope this helps.. Pennie

[Jen 0]

Thanks for the help, Kate & Pennie. I did know it was O.K. for qualified staff to sign-off on any documentation written by non-qualified staff, but have never practiced this as, ulitimately, as you pointed out Pennie, I am responsible for anything in that activity charting.